PATIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

First Name

Last Name

With my consent, Scott Sanders MD, PLLC may use and disclose protected health information (PHI) about me.to carry out treatment, payment, and healthcare operations (TPO). For a more complete description of these uses and disclosures, please refer to the trifold brochure available at the reception desk (Scott Sanders Dermatology, NOTICE OF HEALTH INFORMATION PRIVACY PRACTICES). As a patient, you have the right to review this NOTICE OF HEALTH INFORMATION PRIVACY PRACTICES prior to signing this consent. Scott Sanders MD, PLLC reserves the right to revise its NOTICE OF HEALTH INFORMATION PRIVACY .PRACTICES at any time. A revised NOTICE OF HEALTH INFORMATION PRIVACY PRACTICES may be obtained by forwarding a written request to Scott Sanders MD, PLLC Privacy Officer at 301 North Main Street, -New City, New York 10956.

I, hereby authorize Scott Sanders MD, PLLC and/or their representatives to release any and all information pertaining to my healthcare, results, and procedures and/or accounting information to the following person(s) or agencies:

Myself

Spouse/Partner

Full Name

Parent

Full Name

Other

Full Name (Relationship)

I further authorize Scott Sanders MD, PLLC and/or his representatives to release results of my medical exams in one or more of the following ways:

May call me (patient) — check all that apply:

At home/cell

At work

May leave a message

On answering machine at home/cell

On answering machine at work

With my consent, Scott Sanders MD, PLLC may send by e-mail to my home or other designated location any items that assist the practice in carrying out treatment, payment, and healthcare operations. This includes but is not limited to appointment reminders and patient statements, as long as they are marked “Personal and Confidential.

My preferred email is:

I have the right to request that Scott Sanders MD, PLLC restrict how it uses or discloses my protected health information to carry out treatment, payment, and health care operations. The practice is not required to agree to my requested restrictions. However, if the practice does agree to those restrictions, it Is then bound by this agreement.

By signing this form, | am consenting to Scott Sanders MD PLLC use and disclosure of my protected health information to carry out treatment, payment, and healthcare operations.| may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. | am aware that if | do not sign this consent, Scott Sanders MD, PLLC may decline to provide treatment to me.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Patient or Legal Guardian

Date

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